Delay techniques for nipple-sparing mastectomy: A systematic review.

BACKGROUND: Rare but serious complications of nipple-sparing mastectomy (NSM) include necrosis of the nipple-areolar complex (NAC) and mastectomy skin flaps. NAC and mastectomy flap delay procedures are novel techniques designed to avoid these complications and may be combined with retroareolar biopsy as a first-stage procedure. We performed a systematic review of the literature to evaluate various techniques for NAC and mastectomy flap delay. METHODS: PubMed and Cochrane databases were searched from January 1975 through April 15, 2016. The following search terms were used for both titles and key words: 'nipple sparing mastectomy' AND ('delay' OR 'stage' OR 'staged'). Two independent reviewers determined the study eligibility, only accepting studies involving patients who underwent a delay procedure prior to NSM and studies with objective results including specific outcomes of NAC and mastectomy flap necrosis. RESULTS: The literature search yielded 242 studies, of which five studies met the inclusion criteria, with a total of 101 patients. Various techniques for NSM delay have been described, all of which involve undermining the nipple and surrounding mastectomy skin to some degree. Partial NAC necrosis was reported in a total of 9 patients (8.9%). Mastectomy flap necrosis was reported in a total of 8 patients (7.9%). Three of five studies reported positive retroareolar biopsy findings in a total of 7 patients (6.9%). CONCLUSIONS: Delay procedures for NSM have a good safety profile and may be considered in patients at risk for NAC or mastectomy flap necrosis, such as patients with pre-existing breast scars, active smoking, prior radiation, or ptosis. These procedures have the added benefit of allowing a retroareolar biopsy to be sent for permanent sections prior to mastectomy, allowing the surgical team to plan for the removal of the NAC at the time of mastectomy if indicated and eliminating the risk of a false-negative result on frozen section analysis.

Reconstruction of Defects After Fournier Gangrene: A Systematic Review.

BACKGROUND: Reconstruction of scrotal defects after Fournier gangrene is often achieved with skin grafts or flaps, but there is no general consensus on the best method of reconstruction or how to approach the exposed testicle. We systematically reviewed the literature addressing methods of reconstruction of Fournier defects after debridement. METHODS: PubMed and Cochrane databases were searched from 1950 to 2013. Inclusion criteria were reconstruction for Fournier defects, patients 18 to 90 years old, and reconstructive complication rates reported as whole numbers or percentages. Exclusion criteria were studies focused on methods of debridement or other phases of care rather than reconstruction, studies with fewer than 5 male patients with Fournier defects, literature reviews, and articles not in English. RESULTS: The initial search yielded 982 studies, which was refined to 16 studies with a total pool of 425 patients. There were 25 (5.9%) patients with defects that healed by secondary intention, 44 (10.4%) with delayed primary closure, 36 (8.5%) with implantation of the testicle in a medial thigh pocket, 6 (1.4%) with loose wound approximation, 96 (22.6%) with skin grafts, 68 (16.0%) with scrotal advancement flaps, 128 (30.1%) with flaps, and 22 (5.2%) with flaps or skin grafts in combination with tissue adhesives. Four outcomes were evaluated: number of patients, defect size, method of reconstruction, and wound-healing complications. CONCLUSIONS: Most reconstructive techniques provide reliable coverage and protection of testicular function with an acceptable cosmetic result. There is no conclusive evidence to support flap coverage of exposed testes rather than skin graft. A reconstructive algorithm is proposed. Skin grafting or flap reconstruction is recommended for defects larger than 50% of the scrotum or extending beyond the scrotum, whereas scrotal advancement flap reconstruction or healing by secondary intention is best for defects confined to less than 50% of the scrotum that cannot be closed primarily without tension.